Referrer Details

Representative completing this form
How did you hear about us?

Client Details

LEAP Participant
Gender  

Carer Details

Parent / Guardian / Nominee

Consents

Does the individual have capacity to consent?
Are there any relevant court and/or Administration & Guardianship orders in place?

NDIS Details

Are you happy to provide a copy of your NDIS Plan?  
Do you have a Support Coordinator?  
If yes, please provide details:
How is your plan managed?  
If Plan Managed, please provide details:

About You

Please identify your disability(ies):  
Please identify your support requirement level:  
Does the individual use any equipment or aids?
Impact of Disability
Please detail support requirements in the following areas:
Ability to move within your home and community
Ability to express wants and needs through spoken, written and/or non-verbal methods
Ability to retain information and develop new skills
Ability to connect with others
Ability to care for basic needs such as hygiene and feeding
Ability to organise and make decisions for yourself
Are you of Aboriginal or Torres Strait Islander origin?
Accommodation
Day Activities
Do you have a positive behaviour support plan?
Do you have any care plans in place?

YMCA Services

Please indicate which YMCA Leap Program you are interested in: